435202340-1-7-2025-26-AS-CCHG-DCQ2ZN-20250107165038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202340
Report Date: 01/07/2025
Date Signed: 01/07/2025 04:51:00 PM

Document Has Been Signed on 01/07/2025 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	VENETIAN RESIDENTIAL CARE, INC.		FACILITY NUMBER:	435202340
ADMINISTRATOR/ DIRECTOR:	PAZ BILKEY		FACILITY TYPE:	740
ADDRESS:	4649 VENICE WAY		TELEPHONE:	(408) 873-1670
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Virginia Quezada		TIME VISIT/ INSPECTION COMPLETED:	12:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Virginia Quezada . LPA reviewed 2 resident files and 2 staff files. 1 Out of 2 resident files was observed centrally stored medication form does not match with medications. LPA toured the facility inside and out with HM. LPA observed 2 residents and 3 staff in the facility. License, personal rights posters and Administrator Certificate were observed in the facility. LPA inspected living room, family room, dinning room, kitchen. There are 2 restrooms for residents, a restroom for staff, 2 resident shared rooms, 2 resident single rooms, and 1 staff live-in room in facility. Two days perishable foods and seven nonperishable foods were observed sufficient. Room temperature was observed at 73 degree F, hot water temperature was observed at 110 degree F. The facility has 2 refrigerators. HM stated the facility already ordered a new refrigerator to replace one of the existing refrigerators which will be delivered on 1/17/2025. The temperature of the other refrigerator was observed at 36 degree F, and the temperature of the other freezer was observed at 0 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. Fire extinguisher was serviced on 5/28/2024. The facility was equipped with fire/smoke alarm and carbon monoxide detectors. Carbon monoxide detector was tested, and was working fine. The facility is equipped with emergency light system and back up battery system. The facility has bed alarm detector for resident. It was tested by HM, and was observed working. The facility has call alarm system. It was tested by HM and was observed working. Continue on LIC809-C.

Romeo Manzano	TELEPHONE: (408) 277-1289
Chihhsien Chang	TELEPHONE: (408) 904-9843
	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VENETIAN RESIDENTIAL CARE, INC.	FACILITY NUMBER: 435202340
	VISIT DATE: 01/07/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

First Aid box, flash light and night lights were observed in the facility. The last time the facility conducted the emergency drill was on 8/15/2024. HM stated the facility will start to conduct emergency drill every 3 months in 2025.

Front yard and backyard were inspected. There were two gates at back yard to go outside. There was no obstruction to block the walkway to one gate. The walkway to the other gate is fine to walk through, but needs to trim the branches of the nearby tree. HM stated the facility will trim it in this week. .

Deficiency noted today. See LIC809-D. This report was provided to HM for signature. A copy of this report was emailed to HM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/07/2025 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VENETIAN RESIDENTIAL CARE, INC.	FACILITY NUMBER: 435202340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the centrally stored medication form of resident R1 was observed did not match with R1's medications which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	Administrator stated to submit a plan of correction by the POC due date to ensure the resident centrally stored medication forms are maintained accurate and up to date. Administrator agreed to provide staff training of medications and to submit the staff training log.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Romeo Manzano	TELEPHONE: (408) 277-1289
Chihhsien Chang	TELEPHONE: (408) 904-9843
	DATE: 01/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3